Interpreting high troponin: It's not just for cardiologists anymore
Jan 012012

This nice (and brief) review article on interpreting elevated troponin levels can be summed up by its quote from cardiologist Robert Jesse:

“When troponin was a lousy assay it was a great test, but now that it's becoming a great assay, it's getting to be a lousy test.”

Troponin abnormality is set at the 99th percentile in the healthy population. As troponin tests have become more and more sensitive, the absolute cutoff value for "abnormal" troponin has become lower and lower. As you've undoubtedly discovered, "abnormal" troponin includes a lot of unhealthy people in a lot of clinical situations that don't include occlusion of their coronary arteries by ruptured atherosclerotic plaques (severe hypertension, renal disease, myocarditis, severe sepsis, and many more*).

This is a brief article that reviews the physiology and kinetics of troponin release and clearance, and emphasizes the need for serial troponin testing and evaluating the results in proper clinical context. Although in 1,200 words the authors don't really get you out of all (or maybe any) of the dilemmas of interpreting high troponin levels, it's a good update and it's free full text.

Mahajan VS, Jarolim P. Clinician Update: How to Interpret Elevated Cardiac Troponin Levels. Circulation 2011;124:2350-2354. 

* Many conditions other than acute coronary syndrome cause elevated troponin levels; here are most of them, divided into primary cardiac and noncardiac causes:

Noncardiac Causes of Increased Troponin Levels

  • Renal failure
  • Pulmonary embolism
  • Severe pulmonary hypertension
  • Sepsis
  • Severe critical illness
  • Burns
  • Extreme exertion
  • Amyloidosis or other infiltrative diseases
  • Stroke and subarachnoid hemorrhage

Cardiac Causes of Elevated Troponin (besides ACS)

  • Acute and chronic heart failure
  • Myocarditis
  • Cardiac contusion from trauma
  • Cardioversion
  • Endomyocardial biopsy
  • Aortic dissection
  • Hypertrophic cardiomyopathy
  • Aortic valve disease (aortic stenosis or regurgitation)
  • Cardiotoxic drugs
  • Tachyarrhythmia (SVT, V-tach, atrial fibrillation)
  • Bradyarrhythmia or heart block
  • Cardiac surgery
  • Cardioversion
  • Tako-tsubo cardiomyopathy
  • Rhabdomyolysis
  • Stenting or angioplasty (percutaneous coronary intervention/PCI)


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  6 Responses to “Interpreting high troponin: It’s not just for cardiologists anymore (Review, Circulation)”

  1. My 16 year old son has been in and out of ICU for the past year with elevated Troponin I levels, Troponin has gotten up to 0.606. Doctor can’t seem to find the answer for the chest pain and elevated Troponin… He’s had several imaging done, all kinds of genetic testing and so far we still don’t have an answer to his issue. Can there be anything else causing his chest pain and elevation of Troponin? I am so desperate for answers. Any help will be greatly appreciated.

  2. Hi Karina ~ I was reading your question about your 16 year old son and it kind of surprised me that they don’t have an answer. I was taken to the ER 3 months ago with chest pain, dizziness, and severely low pulse rate. (I’m 37 yrs old) My troponin level was 0.91. I was diagnosed with what’s called Non ST Elevated Myocardial Infarction (or NSTEMI) I was transferred to a leading heart hospital for emergency surgery to have a pacemaker put in.
    After reading your question I looked again at my troponin levels from my discharge paperwork and it actually says underneath my level that less than 0.10 is normal, 0.10 – 0.60 is suggestive of myocardial injury, and anything greater than 0.60 is consistent with myocardial injury. If you look up NSTEMI online, you’ll see that this type of heart attack does not show up on an EKG.
    I am by no means a medical professional and I am just sharing with you my experience and results. I hope this helps in some way and I welcome you to get back to me and let me know what happens. Take care.
    My Email is [email protected]

  3. Good article

  4. NSTEMI in a 16 year old seems unlikely and i would imagine that your doctors wouldnt have done the necessary leg work to rule it out anyway. Essentially an NSTEMI means there is no ST elevation on the ECG but there can still be ischemic changes which are consistent with a myocardial infarction. The troponin range does depend greatly on the hospital. In my hospital anything over 0.04 is considered a positive rise.

  5. Hi Katrina
    My son has POTS. Despite the acute chest pain, the doctors have refused to perform a trop. I believe that this condition also caused widespread vasoconstriction in the coronary vessels. Have the doctors considered this particular if there unexplained widespread variation in his heart rate?